Atrial septal defect physical examination

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Atrial Septal Defect Microchapters

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Overview

Anatomy

Classification

Ostium Secundum Atrial Septal Defect
Ostium Primum Atrial Septal Defect
Sinus Venosus Atrial Septal Defect
Coronary Sinus
Patent Foramen Ovale
Common or Single Atrium

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3] Assistant Editor(s)-In-Chief: Kristin Feeney, B.S. [4]

Overview

Volume overload of the right side of heart can lead to right heart failure that may present with symptoms of swelling of the extremities, difficulty breathing and signs such as hepatomegaly and an elevated jugular venous pulse. On cardiovascular examinations there is a fixed splitting of second heart sound. Also, a systolic ejection murmur that is attributed to the increased flow of blood through the pulmonic valve can be heard.

Physical Examination

The physical findings in an adult with an atrial septal defect depends on:

Heart

Inspection

Palpation

  • Right ventricular impulse: An increased left-to-right atrial shunt can cause a hyperdynamic right ventricular impulse or heave. The heave can be best palpated at the left sternal border or the subxiphoid area.
  • Pulmonary artery pulsations: Pulsatile, enlarged pulmonary artery pulsation can be felt at the second left intercostal space. These are more pronounced in patients with large left-to-right shunts. Patients with obstruction to right ventricular outflow have a less dynamic right ventricular impulse and may present with more of a tapping or thrusting quality.
  • Thrill: In large left-to-right shunt or the presence of a pulmonic stenosis a thrill can be palpated.

Auscultation

  • First heart sound, S1
  • Best heard: at the cardiac apex.
  • It can be split. The reason behind the split is that the large volume of diastolic blood flow from right atrium to right ventricle causing forceful contraction of the tricuspid leaflets.
  • Second heart sound, S2
  • Best heard: at the second inter-costal space at the upper left sternal border.
  • Fixed splitting of the second heart sound (S2) is present.
  • It should be evaluated with the patient sitting or standing.
  • Commonly seen with large left-to-right shunt and absence of pulmonary hypertension.
  • In unaffected individuals, there are respiratory variations in the splitting of the second heart sound (S2). During respiratory inspiration, the negative intrathoracic pressure causes increased blood return into the right side of the heart. The increased blood volume in the right ventricle causes the pulmonic valve to stay open longer during ventricular systole. This causes a normal delay in the P2 component of S2. During expiration, the positive intrathoracic pressure causes decreased blood return to the right side of the heart. The reduced volume in the right ventricle allows the pulmonic valve to close earlier at the end of ventricular systole, causing P2 to occur earlier. In individuals with anatrial septal defect, there is a fixed splitting of S2. Fixed splitting occurs as a result of the extra blood return during inspiration equalized by the intraseptal communication between the left and right atrium allowed by the defect. Fixed splitting of S2 is rare with ASDs in newborns as they have little left-to right shunts.

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Murmurs

Several different types of murmur can occur in atrial septal defect:

  • Rumbling middiastolic murmur
  • Crescendo-decrescendo systolic ejection murmur
  • Midsystolic pulmonary flow or ejection murmur
  • Heard best at 2nd intercostal space at upper left sternal border.
  • Heard commonly in moderate to large left-to-right shunts.
  • Occur due to increased right ventricular stroke volume across pulmonary outflow tract.
  • Systolic crescendo-decrescendo murmur
  • Audible over the lung fields and is thought to occur from rapid flow through the peripheral pulmonary arteries.
  • Pansystolic mitral regurgitation murmur
  • Widely split S2, S3 and S4 can be heard on auscultation. These heart sounds get accentuated with inspiration.
  • Low-pitched murmur, best heard along the third or fourth intercostal spaces adjacent to the left sternal border.
  • When the pulmonary artery systolic pressure exceeds 70 mm Hg, dilatation of the pulmonary artery ring may then result in Graham-Steell's murmur. This is a high-pitched, blowing decrescendo murmur heard best along the left parasternal region.
  • Left-to-right shunt in atrial septal defect causes increased flow through the pulmonary vasculature, which can lead to pulmonary hypertension. This pulmonary hypertension may finally cause increased pressures in the right side of the heart and reversal of the shunt into a right-to-left shunt. Auscultatory findings accompanying pulmonary hypertension are-
  • Increased intensity of the pulmonic component of S2, but no fixed splitting
  • Fourth heart sound (right ventricular)
  • Midsystolic ejection click
  • Absence of tricuspid flow murmur
  • A holosystolic murmur of tricuspid insufficiency
  • Midsystolic pulmonic murmur
  • A high pitched pulmonic regurgitation murmur

Abdomen

Extremities

Neurologic

Other

  • Jugular venous pressure may be raised with 'a' wave indicating increased right atrial pressure. A "v" wave indicating development of tricuspid regurgitation may also be seen.

References

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